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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton , California 95202 <br /> Telephone : (209) 46 $-3420 Fax : (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW : <br /> TANK RETROFIT Ia PIPING REPAIR/RETROFIT UDC REPAIR/ RETROFIT B COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Marty Weithman 408-213 -6038 <br /> AFacilit NPhone # <br /> C Facility Speedway 209-368-8787 <br /> I Address <br /> L 401 W Kettleman Lane , Lodi CA 95240 <br /> I Cross Street Hutchins <br /> T <br /> Y Owner/Operator Speedway Phone # 253-896-8809 <br /> c Contractor Name Service Station Systems , Inc Phone # <br /> Q y 408-213-6038 <br /> N Contractor Address 680 Quinn Ave , San Jose CA 95112 CA Lic # 485184 Classg C61 /D40 H!b <br /> R Insurer <br /> A Insurance Company of the West Work Comp # WPL 5021307 <br /> T ICC Technician 's Name Brian McPheeley Expiration Date 11 / 1 /2021 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P 5 Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> A 3 � z� <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR CE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : 1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. ' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature rte. ' �' L V Tme Compliance Officer pate 3/ 12/2020 <br /> BILLING INFORMATION . <br /> Indicate the responsible party to be billed for additional END staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e .g . property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Marty Weithman TITLE Compliance Officer PHONE # 408-213-6038 <br /> ADDRESS 6880) Quinn Ave . San Jose , 95112 <br /> SIGNATUREyt � dil.�.1 /�l+ � f�—Q'Ly DATE 3/ 12/2020 <br /> EH230038 (revised 02/20/09) <br /> 1 <br />